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NC hospital systems reduce re-admissions, decrease patient harm

In a six-month span last year, Gwen Frank-Robinson went to the hospital four times for complications related to chronic medical problems.

But in the past four months, she’s been to the emergency room only once, for a nose bleed.

What changed?

She got help from Sarah Lacy, a nurse in the advanced illness management program at Carolinas HealthCare System. Lacy supports patients who are at high risk for complications and helps keep them from being re-admitted unnecessarily to the hospital.

Since they met in February, Lacy has visited Frank-Robinson, 71, at home in east Charlotte and spoken to her at least weekly. Lacy makes sure she understands everything about managing her health.

It’s part of a national movement to avoid preventable injuries and complications in hospitals and to reduce re-admissions by reaching out to patients with complex medical conditions and making sure they’re clear about doctors’ orders and medications. Avoiding confusion over those two issues alone can save millions of dollars in unnecessary medical expenses.

Carolinas HealthCare and Novant Health have been part of a pilot project launched by the federal Centers for Medicare and Medicaid Services in 2011. The goal of the Partnership for Patients and its 26 hospital networks is to make health care safer and less costly by reducing preventable injuries and complications, such as falls and hospital-acquired infections.

In May, the federal Department of Health and Human Services reported a 9 percent decrease in “patient harm” in hospitals nationally during 2011 and 2012, with nearly 15,000 deaths prevented and a savings of $4.1 billion in health care costs. Part of that improvement was credited to Partnership for Patients, which includes the two hospital networks in the Carolinas.

In the past two years, Carolinas HealthCare’s 29 participating hospitals have prevented an estimated 4,400 “patient safety events” and saved more than $17 million in health care costs, according to the system’s report to the federal government.

Winston-Salem-based Novant, with four hospitals in Mecklenburg, participated as part of the North Carolina-Virginia network through the North Carolina Hospital Association. Results for Novant alone are not available, but the network’s 116 hospitals prevented about 4,500 incidents of patient harm for a savings of $42 million since December 2011.

“We need higher quality, safer care, and it needs to be less expensive,” said Dr. Tom Zweng, Novant’s chief medical officer. “A lot of people say that’s impossible. But if you get intentional, you can improve the quality of care, it can be done in a safer fashion, and you can do it for less cost.”

Good business sense

Specific goals for the partner hospitals were to reduce re-admissions within 30 days of discharge by 20 percent and reduce preventable incidents of patient harm by 40 percent.

Carolinas HealthCare reduced re-admissions by 15.7 percent on average for all causes. In 2010, nearly 18 percent of patients who had been hospitalized for heart attack, heart failure or pneumonia were re-admitted within 30 days of discharge. By January 2014, that dropped to 12.5 percent.

All re-admissions are counted, even if they’re unrelated to the original problem. “It could be that we do everything right for that patient and they get into a bus accident and come back to the hospital, but we still count that,” said Jason Byrd, the system’s director of patient safety.

In other areas, the system exceeded goals. For example, there was a 73 percent reduction in early elective births and a 51.7 percent reduction in pneumonia associated with ventilator use.

Dr. Roger Ray, chief medical officer for Carolinas HealthCare, said federal estimates of related cost-savings prove that good patient care also makes good business sense. “It’s a better experience for the patient. … And it’s actually a cost savings to payers (such as private insurers, Medicare and Medicaid),” Ray said. “There is a business case for improving quality.”

The North Carolina-Virginia group reduced re-admissions by only 3 percent, but its spokeswoman, Julie Henry, said that was partly because “some of the hospitals were farther ahead in quality improvement efforts than others.” She praised the success at Carolinas HealthCare and added that being part of a unified system makes it easier to standardize practices.

“It’s all about finding out what really works and taking it to the next level,” Henry said. “The important thing is that everybody is trending in the right direction. This has helped kick-start quality improvement efforts so we can keep moving forward.”

Focus is reducing patient harm

For many reasons, hospitals across the country have become more focused on improving patient care – and preventing harm.

In 1999, the Institute of Medicine first raised public awareness about the extent of the problem with a report that preventable errors caused up to 98,000 deaths each year, with an associated cost of $17-$29 billion.

This effort has accelerated since 2012 when Medicare, the federal health program for seniors, began levying penalties against hospitals that had too many patient re-admissions within 30 days of discharge for three medical conditions (heart failure, heart attack and pneumonia.) Nationally, thousands of hospitals incurred the maximum fine, having 2 percent of their Medicare reimbursement withheld.

Many Charlotte-area hospitals have been fined for having too many re-admissions. Carolinas Medical Center is having 0.29 percent of its reimbursement withheld this year. Novant Health Presbyterian Medical Center was fined 0.18 percent. Hospital officials note that those latest Medicare penalties were based on results from 2008 to 2011, whereas the results for the Partnership for Patients pilot project were more recent, from 2010 to 2012.

Medicare also penalizes hospitals that don’t meet certain levels for infections and other hospital-acquired conditions. In recent weeks, Kaiser Health News published a preliminary list of the hospitals likely to be fined this year. They include Carolinas Medical Center-NorthEast in Concord and Cleveland Regional Medical Center in Shelby, both part of Carolinas HealthCare System.

These penalty programs are part of the federal government’s move toward a “value-based” health care system that pays hospitals for the quality of their performance instead of the current “volume-based” system that pays for the number of patients treated and procedures performed.

In the two-year pilot project, the Partnership for Patients enlisted participating hospitals to identify best practices for reducing patient harm and to share them with each other. One area of focus was the rising rate of early elective births because some mothers and doctors schedule deliveries for convenience instead of medical necessity. Babies are generally healthier if they are born at full term of nine months.

Since 2010, Carolinas HealthCare has reduced early elective deliveries from 9.6 percent of all births to under 2 percent. Some months, it’s under 1 percent or even zero, Byrd said. “That’s an incredible reduction in a short period of time.”

Hospitals have also prevented harm and extra cost by intervening with patients, such as Frank-Robinson, who are at high risk for complications.

Using electronic medical records, analysts at Carolinas HealthCare identify patients who have been hospitalized more than twice in a six-month period and who also take multiple medicines for chronic conditions.

Then nurses and social workers review records to decide which patients could benefit from extra support. These teams “tackle patients who are really susceptible to falling through the cracks” because they might not have home support or be able to afford their medicines, Byrd said.

In the six months before they were assigned to a team, the first 25 patients logged 97 visits to emergency rooms or hospitals. In the nine months since, their hospital visits were down to 22. One patient who had been to the emergency room seven times in six months beforehand has now gone 100 days without a visit.

Questions get answered

Frank-Robinson was one of those first 25 patients. Her health has improved dramatically since she met nurse Lacy at Carolinas Medical Center in February. She was being treated for an abdominal abscess, a complication from multiple back surgeries to treat osteoarthritis.

After Frank-Robinson was discharged, Lacy visited her home to assess the environment and make sure she had everything she needed.

Lacy answers questions about the doctors’ orders and makes sure Frank-Robinson remembers her appointments, has transportation, and understands why and when to take her medicines for diabetes and high blood pressure. She has given Frank-Robinson her cellphone number and encourages her to call anytime.

“Sometimes patients leave without having a full understanding of what the doctor has said to them,” Lacy said. “They don’t always know what to ask. Some of them are afraid to talk to the doctor.”

Frank-Robinson knows the feeling. “When you’re dealing with doctors, a lot of time the clock is ticking, and you don’t have time to ask a lot of questions. … Sarah (Lacy) would call me, and she already knew what the doctor had said, and she would explain to me what it all meant.”

The nose bleed that brought Frank-Robinson to the ER in May began during church, and she couldn’t get it to stop. Lacy said it happened because Frank-Robinson had followed her advice to use a portable oxygen unit to ease breathing difficulties from chronic obstructive pulmonary disease. But without a humidifier, the air dried out her nasal passages. Lacy helped get a humidifier – and prevent another trip to the hospital.

Frank-Robinson appreciates the help: “It’s a very comforting feeling to know that I can pick up the phone and call Sarah.”

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